Therapeutic hypothermia and N-PASS; results from implementation in a level 3 NICU

BACKGROUND

Neonates that have been subjected to perinatal asphyxia and fulfill criteria for therapeutic hypothermia are cooled to 33.5 °C for 72 h. There is no consensus regarding sedation and analgesic use during hypothermia, but there is evidence supporting the importance of pain relief and adequate sedation. There is a need for assessment of the neonates need for pain relief and sedation, and for adjustments of medication to ensure adequate treatment. There are many different scoring tools available. We found the N-PASS (Neonatal Pain, Agitation and Sedation Scale) scoring tool to be the most suitable for this patient group as it assesses both pain and sedation.

METHODS

We translated the scoring tool according to guidelines published by Wilder et al., and scored neonates treated with therapeutic hypothermia. Sedation and analgesia were adjusted according to scoring results. At the end of the study a questionnaire was filled out by the nurses in charge of this group of patients.

RESULTS

Both pain and sedation scores did not reach the desired levels until day 3. The nurses reported a high level of satisfaction (79.7% were extremely of very satisfied), and 96.7% of the nurses found the neonates to be better pain relieved after the initiation of the study.

CONCLUSION

The implementation of the N-PASS scoring tool in our unit has been successful, and has led to better pain relief and sedation than before the implementation.

A phase II/III, multicenter, safety, efficacy, and pharmacokinetic study of dexmedetomidine in preterm and term neonates

OBJECTIVE

To investigate the safety, efficacy, and pharmacokinetic profile of dexmedetomidine in preterm and full-term neonates ≥ 28 to ≤ 44 weeks gestational age.

STUDY DESIGN

Forty-two intubated, mechanically ventilated patients (n = 42) were grouped by gestational age into group I (n = 18), ≥ 28 to <36 weeks, and group II (n = 24), ≥ 36 to ≤ 44 weeks. Within each age group, there were 3 escalating dose levels, including a loading dose (LD, μg/kg) followed by a maintenance dose (MD, μg · kg(-1) · h(-1)) for 6-24 hours: level 1, 0.05 LD/MD; level 2, 0.1 LD/MD; and level 3, 0.2 LD/MD. The primary endpoint was the number of patients requiring sedation as determined by the Neonatal Pain, Agitation, Sedation Scale.

RESULTS

During dexmedetomidine infusion, 5% of Neonatal Pain, Agitation, Sedation Scale scores were >3, indicating agitation/pain, with 4 patients (10%) requiring more sedation and 17 (40%) requiring more analgesia. Though there was significant variability in pharmacokinetic variables, group I appeared to have lower weight-adjusted plasma clearance (0.3 vs 0.9 L · h(-1) · kg(-1)) and increased elimination half-life (7.6 vs 3.2 hours) compared with group II. Fifty-six adverse events (AEs) were reported in 26 patients (62%); only 3 AEs (5%) were related to dexmedetomidine. There were no serious AEs and no AEs or hemodynamic changes requiring dexmedetomidine discontinuation.

CONCLUSION

Dexmedetomidine is effective for sedating preterm and full-term neonates and is well-tolerated without significant AEs. Preterm neonates had decreased plasma clearance and longer elimination half-life.

Successful implementation of a neonatal pain and sedation protocol at 2 NICUs

OBJECTIVE

To evaluate the implementation of a neonatal pain and sedation protocol at 2 ICUs.

METHODS

The intervention started with the evaluation of local practice, problems, and staff satisfaction. We then developed and implemented the Vienna Protocol for Neonatal Pain and Sedation. The protocol included well-defined strategies for both nonpharmacologic and pharmacologic interventions based on regular assessment of a translated version of the Neonatal Pain Agitation and Sedation Scale and titration of analgesic and sedative therapy according to aim scores. Health care staff was trained in the assessment by using a video-based tutorial and bedside teaching. In addition, we performed reevaluation, retraining, and random quality checks. Frequency and quality of assessments, pharmacologic therapy, duration of mechanical ventilation, and outcome were compared between baseline (12 months before implementation) and 12 months after implementation.

RESULTS

Cumulative median (interquartile range) opiate dose (baseline dose of 1.4 [0.5-5.9] mg/kg versus intervention group dose of 2.7 [0.4-57] mg/kg morphine equivalents; P = .002), pharmacologic interventions per episode of continuous sedation/analgesia (4 [2-10] vs 6 [2-13]; P = .005), and overall staff satisfaction (physicians: 31% vs 89%; P < .001; nurses: 17% vs 55%; P < .001) increased after implementation. Time on mechanical ventilation, length of stay at the ICU, and adverse outcomes were similar before and after implementation.

CONCLUSIONS

Implementation of a neonatal pain and sedation protocol at 2 ICUs resulted in an increase in opiate prescription, pharmacologic interventions, and staff satisfaction without affecting time on mechanical ventilation, length of intensive care stay, and adverse outcomes.